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Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 449-453
Lip designing: The need for a beautiful smile: An Indian perspective

Department of Dermatology, Cosmetic Surgery Institute, Santacruz (W), Mumbai, Maharashtra, India

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Date of Submission08-Feb-2014
Date of Decision31-Mar-2014
Date of Acceptance19-Aug-2014
Date of Web Publication10-Oct-2014


Background: Smile is the defining element of the face, its impact holding utmost importance in the perception of feelings. Lip is an integral part for a perfectly perceived smile. The aim of the present manuscript is to present an innovative approach to smile improvement by lip design in Indian context.
Materials and Methods: Thirty-five patients who had undergone smile design (lip) in the institute were taken up for retrospective analysis. The technique of using fillers for lip augmentation was assessed, and the final result evaluated.
Results: Demographic details are presented . We observed that the upliftment of the lips was more visible, and the fillers enhanced the volume resulting in an attractive smile.
Conclusion: Smile reconstruction has been revolutionized by the new filler materials for volume augmentation of lips. We advocate this novel approach of lip design using fillers to generate a gorgeous smile.

Keywords: Facial cosmetic surgery, hyaluronic acid, lip augmentation, lip fillers, smile designing

How to cite this article:
Thomas M, D' Silva J, Kohli S, Sarkar S. Lip designing: The need for a beautiful smile: An Indian perspective. Indian J Dent Res 2014;25:449-53

How to cite this URL:
Thomas M, D' Silva J, Kohli S, Sarkar S. Lip designing: The need for a beautiful smile: An Indian perspective. Indian J Dent Res [serial online] 2014 [cited 2021 Apr 18];25:449-53. Available from:
A smile is a primary facial expression formed by the interplay of the circum-oral muscles. [1] It is defined as facial expression, characterized by an upward curving of the corners of the mouth and indicating an emotion. Cross-cultural studies across the world have repeatedly demonstrated that smiling is the most common means of communication and universal expression of happiness. [2]

Understanding the anatomy of a smile would help to deliver better smile in dentistry. Besides the size of teeth, high and low lip lines, size of the mouth, a shade to blend with the age, complexion, there are several other factors such as the length, breath, fullness of the lips that determine the smile. To create a harmonious smile, the dentist must maintain or create the normal curvature of the lips, proper exposure of the red zone of the lips, an undistorted philtrum, and undisturbed nasolabial grooves. These entities, maintained in harmony with the exposed teeth, constitute the anatomy of a perfect smile. [3]

The consideration of the appearance of the lips within the context of the face as a whole is crucial. The lips should be in balance with surrounding soft tissue and skeleton of the midface. Excessive augmentation in an individual with relative midface hypoplasia, for example, may appear very unnatural and unattractive. [4] It is now possible to change the appearance of the lips in several ways, whether to enlarge, reduce, or reconstruct after trauma or surgical resection. There are a growing number of techniques available, including both implantable and injectable materials, utilizing biomaterials, autogenous grafts, and alloplasts. [4]

There are few reports of patient's  perception, experience, acceptance and outcomes of lip augmentations from this part of the world. This study was undertaken to address this lacuna. In the present manuscript, authors undertook a retrospective chart review of subjective patient satisfaction feedback and objective findings noted by the authors. This was carried out by reviewing their experience of lip augmentation using Hyaluronic acid (HA) as an injectable material for the correction of lip.

   Materials and methods Top

The objective of this retrospective, single-center, approved-product study was to demonstrate the safety and effectiveness of HA injectable material for lip augmentation. Patients who were operated in the time frame from July to October 2013 in our center were enrolled for the study. This was a retrospective study, the data of which were collected from patient records, without recording their personal details or such pointers. Hence, this study did not require any Ethical approval. Standard protocols in treatment, delivery of care and follow-up schedules were vigorously adhered to. Previous similar studies [5] have been followed in detail with modifications as mentioned below.

All patients greater than 18 years of age, of either gender seeking treatment for lip augmentation, were enrolled for the study. Patients requiring treatment at the cutaneous and mucosal lips including the vermilion, vermilion borders, Cupid's bow and philtral columns, perioral lines, and oral commissures, with a maximum volume of 2 mL of gel were enrolled for this study. Subjects who desired lip enhancement, had a realistic lip fullness treatment goal, had lip fullness of minimal or mild on the 4-point lip fullness scale (LFS) (minimal, mild, moderate, and marked) [5] and were at least 18 years old were eligible for study participation patients who had been surgically treated with semi-permanent fillers or permanent implants in the lips. Patients with unrealistic expectations, with scars, with systemic illness were excluded from the study. Injectable form of HA gel was used for these patients. Following injection with HA, subjects returned to the clinic for follow-up at 1 and 3 months after initial treatment. No optional top-up treatment was considered for this study. At baseline, investigators used the previously published [6] validated LFS to assess current lip fullness and formulate a lip fullness goal with the consultation of the patients. LFS was then assessed by surgeons and patients perception noted at 1 st and 3 rd post-operative months. Adverse events were collected at all clinic visits and via telephone calls to subjects after each treatment.

Safety follow-up via telephone occurred 3-5 days after each treatment. Lip fullness was noted at the phases of each treatment.

   Surgical anatomy Top

The upper lip consists of three subunits: the central philtrum and the two lateral subunits. The lower lip is a single subunit [Figure 1]. Facial analysis commonly divides the face into horizontal thirds [Figure 2], the lower one-third of the face consists of the portion from the subnasale to the menton. Within this lower third of the face, the lower lip (lower vermilion border to the menton) is twice the height of the upper lip complex (subnasale to upper vermilion border). The upper lip is notable for the characteristic Cupid's bow complex. This is created by two high points of the vermilion adjacent to the inferior point of the philtral ridges, with a sloping depression between them in the central lip. These characteristics are to be preserved at all costs with augmentation procedures.
Figure 1: Subunits of lip

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Figure 2: Facial analysis - horizontal landmarks

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The lips consist externally of skin and mucosa. The relaxed skin tension lines of the lip are oriented radially from the vermilion border. The upper lip includes the skin from the subnasale to the vermilion border and the mucosa. At the border of the cutaneous portion to the mucosa the vermilion border, is a raised area of skin of variable prominence known, as a "white roll" [Figure 3]. This structure is a useful landmark not only for reconstructive procedures, but in lip augmentation. The mucosa, or vermilion, includes the "dry" and "wet" portions. The vermilion is red because of the absence of keratin and the closely underlying rich vascular plexus. Deep to the mucosa is an abundant layer of minor salivary glands. The orbicularis oris is a circular muscle running circumferentially around the entrance to the oral cavity. This muscle is largely responsible for the bulk of the lips and functions primarily in oral competence. The muscle is innervated by the facial nerve, and the branches supplying the orbicularis oris enter into the deep surface of the muscle. Sensory innervation is via the trigeminal nerve, which receives contributions from V2 and V3. The blood supply is via the labial artery. This branch of the facial artery is located deep to the mucosa and orbicularis oris. [4]
Figure 3: Perioral landmarks in the lip region to be considered for lip augmentation

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   Procedure Top

Before the injection, informed consent was obtained from the patient. The majority of patients received a combination of topical, local, and regional anesthesia. Topical anesthetic creams include benzocaine, lidocaine and lignocaine are applied 20 min before injection of local anesthesia. Regional anesthesia included infraorbital and mental nerve blocks with 1% lidocaine and 1:200,000 epinephrine. Supplemental, low-volume local anaesthetic was given in the perioral area, with an average of 1.5 cc of 0.5% lidocaine per side with 1:200,000 epinephrine, buffered with 0.5 cc of bicarbonate, and injected via a 30-gauge needle. White roll was created by using the retrograde injecting technique and lip volume enhancement was done by using the cross hatching technique.

Serial puncture technique [Figure 4] involving, multiple injections were made serially along the lip. The injection sites were close together so that the injected material merges into a smooth, continuous line that ultimately lifts the lip. It is helpful to pull the skin slightly away and out from the injection area, while injecting. Care was taken to ensure that no spaces remain between the serially injected materials. If some minimal gaps were present, post-injection moulding and massage can be used to blend the material into a smooth layer. [7]
Figure 4: Infographics showing the serial puncture technique

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The vermilion cutaneous borders are best treated using linear threading [Figure 5]. The full length of the needle is inserted into the middle of the lip line to create a channel. The product is usually injected, while the needle is slowly pushed forward, so that "threads" are deposited along the length. One can inject, while advancing the needle, which may push blood vessels out of the way, or one can utilize retrograde injection technique, inserting product, while retracting the needle from the tissue. [7]
Figure 5: Infographics showing linear threading technique

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All the details of age, gender, number of vials required, satisfaction and LFS were entered and analyzed. Descriptive statistics was presented.

   Results Top

Of the 35 patients, who had undergone lip augmentation at center between July to October 2013 were taken up for the analysis. 15 (42.85%) patients were in the younger age group (25-35 years) and 20 (57.15%) patients were in the older age group (36-53 years). The mean age group was 39.23 ± 8.2 years. The females constituted the larger percentage of the analysis group, 32 (91.43%) being females and 3 (8.57%) males.

Of all patients receiving injections in the lip augmentation subgroup, 19 (54.28%) patients had upper lip only, 11 (31.42%) patients had lower lip only, and 5 (14.29%) patients had combined upper and lower lip. Twelve cases (34.28%) required below 0.8 ml while 10 (28.57%) of cases required 0.8-1.2 ml of HA. The remaining patients required up to 2 ml of HA. No secondary treatments were required in this cohort. Patients experienced mild discomfort during injection and in the immediate post-injection period. Thirty-three (94.28%) of the 35 patient's reported complete satisfaction.

In all patients, on palpation, the areas injected with HA appeared to blend into surrounding tissues smoothly in most patients. However, a lip texture characterized by localized lumpiness suggestive of augmentation was detected in few individuals, but only one of this patient reported awareness of the implant in the early phase that later subsided.

The comparison of LFS between phases of visits did not yield a significant difference. All patients were satisfied and happy with the results assessed on the basis of a questionnaire prepared as per Likert scale.

   Discussion Top

First isolated more than 70 years ago, HA is a naturally occurring, highly hydrophilic glycosaminoglycan polymer. An average-sized human is composed of approximately 15 g of HA, which is found mostly in the extracellular matrix of connective tissue and serves as the ground substance of dermis, fascia, and other tissues. An estimated one-third of the human body's HA is turned over daily. The naturally occurring molecule is easily broken down by the enzyme hyaluronidase. Therefore, chemical modification through cross-linking these molecules is necessary to produce effective filler. Cross-linking provides decreased surface area for degradation to take place. [8] The hydrophilic nature of HA is the key to its clinical usefulness; 1 g of HA can bind 6 L of water. This feature allows for its unique ability to maintain the hydration of the intracellular matrix in which cells are organized and thereby maintain tissue volume and support for surrounding tissues. HA is also unique because it is not species- or tissue-specific, giving it essentially no antigenic specificity. Therefore, it has a very low risk for allergic response in clinical use. The HA products currently available vary in the source through which they are purified and more importantly, the uniform size of the molecules. [9] This property, in particular, gives each product its unique characteristics. HA products have been characterized as a "cement" that hold the collagen "bricks" together. [10],[11] There are various US Food and Drug Administration approved products available in the market to meet the increasing demands-Restylane ® , Perlane ® , Juvederm ® , Mesolis ® .

With multiple filler products being available, it is helpful to have a sense of which product should be used in which situation. For example, more viscous fillers may be used to increase lip volume, but are generally not recommended because of their short duration of effect. Less viscous collagen agents may be more appropriate for the superficial dermis. Layering of fillers in superficial, as well as deep plane, may yield the best result. Furthermore, unlike collagen injections that lose volume over just a few weeks, HA products are hygroscopic and may increase correction by 10-15% after injection. [9] When injecting the lips with HA fillers, physicians must consider the three injectable components the vermillion border or white roll, the wet-dry junction of the red lip and dental arcade that provides volume throughout the mucosa to the superior lip. As a rule of thumb, the upper lip should be approximately 75-80% the volume of the lower lip and the central lower lip should protrude slightly beyond the upper lip. [9]

In our clinical experience (not included in the present study), we identified fanning modality not to be useful. In this technique, the needle is inserted in a fashion similar to that used in the linear threading technique, but immediately before the needle is withdrawn, its direction is changed, and a new line is injected (without withdrawing the needle tip from the skin). The fanning pattern of lines should be evenly spaced in a progressive clockwise or counter-clockwise direction so that the contour is evenly filled and shaped. In an ideal situation, this demands highly precise control of drug delivery in a limited area. This renders this technique a highly sensitive one. The currently studied cross-hatching [Figure 6] is especially effective for filling lips. The needle is inserted in a fashion similar to that used in the linear threading technique, but before beginning the procedure the cross-hatching lines should be carefully demarcated. A series of linear threading injections is made in the treatment region. The pattern of lines should be evenly spaced in a progressive grid so that the contour is evenly filled and shaped. [11]
Figure 6: Infographics to show the cross hatching method for lip augmentation

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Restylane ® or various collagen products can be injected into the vermillion border to emphasize the contour of lip and white roll. Various HA products, such as Perlane ® , may be used for the mucosa of the lips. It is injected into the submucosa to define shape and restore lost volume of lip mucosa. [10] Patients should be forewarned that all HA products may result in nodule formation. In the present study, we did not encounter any such instances. Lip injections can also be painful and perioral nerve block should be strongly considered before treatment. This complication or any adverse situation was not encountered in the present study.

As with all esthetic procedures, accurate and comprehensive aesthetic analysis is the first step. HA fillers are more viscous than collagen material, and injection may be more difficult until familiarity with the product is attained. While materials with smaller particle sizes, such as Restylane ® , flow more easily from the syringe, and demonstrate less tissue resistance when injected in the proper plane, it is still imperative to release them aterial from the syringe in a smooth and even fashion to avoid lumping and surface irregularities. [8]

In the current clinical experience, we identified that optimal lip rejuvenation involves two main components volume enhancement and vermilion cutaneous border enhancements. Volume filling is often required in, older patients and those who have thin lips. Vermilion cutaneous enhancement is usually required in younger individuals who have enough volume, but it is also indicated in older patients, along with volume augmentation. Linear threading and/or serial puncture techniques are implemented starting, at the oral commissures and proceeding in a lateral to medial direction. Marionette lines are a key element in overall, lip enhancement; otherwise, results are destined to be disappointing to both the patient and the physician. A cross-radial technique is used around the oral commissure and marionette line to enhance and "lift" or fill in the corners of the mouth. Care should be taken to avoid superficial injection in this region as a light, blue hue may become visible. Intra-injection and post-injection palpation for surface irregularities is important. If material tracks away from the intended injection plane and created a tunnel, then immediate massage is necessary to recontour the area. Massaging should be instituted immediately by a physician as this is the best time to achieve moulding and shaping. This avoids later discomfort that can be present if the patient is given that task. [8] Injection of the lip itself can be accomplished at the submucosal level within the superficial orbicularis oris muscle mass. Placing the HA in this deeper level decreases its visibility and augments lip volume. Augmentation of the philtral columns can further enrich the lip augmentation.

The final result of overall lip rejuvenation should be evident immediately after the injections, unless excess bruising and edema are present. Immediate swelling is uncommon, and maybe a result of histamine release or immediate particle expansion by water absorption. Bruising, if present, should be controlled with compression during the injection, so that there is no compromise of the final result from blood staining or volume due to extravasated blood.

   Conclusion Top

We have presented an Indian experience with smile designing and  patient's acceptation of the same. To the best of our knowledge, this is first of its kind to document the patient's perception of lip augmentation. Furthermore, this article stresses that in Indian context too, lip design is an essential and indispensable component of smile design bringing forward the novel approach to reshaping smile by lip design.

   References Top

1.Freitas-Magalhães A, Thomas M. The neuropsychophysiological construction of the human smile. In: Freitas-Magalhães A, editor. Emotional Expression: The Brain and the Face. 1 st ed. Oporto, Portugal: University Fernando Pessoa Press; p. 1-18.  Back to cited text no. 1
2.Izard CE. The Face of Emotion. 1 st ed. New York: Appleton-Century-Croft; 1971. p. 18.  Back to cited text no. 2
3.Matthews TG. The anatomy of a smile. J Prosthet Dent 1978;39:128-34.  Back to cited text no. 3
4.Byrne PJ, Hilger PA. Lip augmentation. Facial Plast Surg 2004;20:31-8.  Back to cited text no. 4
5.Carruthers A, Carruthers J, Hardas B, Kaur M, Goertelmeyer R, Jones D, et al. A validated lip fullness grading scale. Dermatol Surg 2008;34 Suppl 2:S161-6.  Back to cited text no. 5
6.Eccleston D, Murphy DK. Juvéderm(®) Volbella™ in the perioral area: A 12-month prospective, multicenter, open-label study. Clin Cosmet Investig Dermatol 2012;5:167-72.  Back to cited text no. 6
7.Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane) in facial cosmetic surgery: Review and technical considerations. Plast Reconstr Surg 2007;120:41S-54.  Back to cited text no. 7
8.Monhian N, Ahn MS, Maas CS. Injectable and implantable materials for facial wrinkles. In: Papel ID, editor. Facial Plastic and Reconstructive Surgery. 2 nd ed. New York: Thieme Medical Publishers; 2002. p. 247-61.  Back to cited text no. 8
9.Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast Surg Clin North Am 2007;15:491-500, vii.  Back to cited text no. 9
10.Monheit GD. Hyaluronic acid fillers: Hylaform and Captique. Facial Plast Surg Clin North Am 2007;15:77-84, vii.  Back to cited text no. 10
11.Ahn MS. Calcium hydroxylapatite: Radiesse. Facial Plast Surg Clin North Am 2007;15:85-90, vii.  Back to cited text no. 11

Correspondence Address:
Mohan Thomas
Department of Dermatology, Cosmetic Surgery Institute, Santacruz (W), Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.142526

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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